Tailored Spasticity Interventions Improve Patient Outcomes Across the Lifespan

In part 1 of this Q&A, Evi Arthur, Associate Digital Editor of the Neurology Learning Network, engages with Cindy Ivanhoe, MD, clinical professor of physical medicine and rehabilitation at McGovern Medical School at The University of Texas Health Science Center at Houston, Texas, to explore the intricate challenges of spasticity management.

Dr Ivanhoe discusses everything from treatment variations between pediatric and adult patients to botulinum neurotoxin use and the nuanced factors influencing candidate selection to the profound impact of untreated spasticity on long-term functional outcomes. Dr Ivanhoe's insights emphasize the importance of tailored interventions and the considerations involved in optimizing patient outcomes. She provides a valuable perspective on the multifaceted challenges and considerations in treating spasticity across diverse patient populations.

Continue on to part 2 of this Q&A: Maintaining the 'Human Touch' in Spasticity Care

Answers have been lightly edited for clarity.

Evi Arthur, Associate Digital Editor, Neurology Learning Network: What are the key challenges in assessing spasticity in pediatric patients compared to adults? How does the approach to management differ across age groups?

Dr Cindy Ivanhoe, MD: A major consideration in treating pediatric patients is that they're growing. There are also developmental milestones to consider and some controversy on the best way to allow motor milestones to occur and the different available interventions. I think you'll find in treating spasticity along the way that there are differing philosophies, and they're going to vary on each patient's situation. Management is going to differ based on the social determinants of health and what is accessible and what can be covered, unfortunately. 

Arthur, NLN: What evidence supports the use of botulinum neurotoxins in the management of spasticity? What factors should be considered when determining the appropriate candidates for this intervention?

Dr Ivanhoe: There is so much evidence and many factors to be considered when determining appropriate candidates for this intervention. For one thing, we tend to look at things like scores more than we look at individual goals for a particular patient. When I'm teaching, lecturing, or talking to residents, I will always say, ‘What is the goal of your intervention?’ We are increasingly limited with how much we can inject patients with, and that is due to funding sources and other little glitches in how insurance is provided.

Most of us know that if you give higher doses, you tend to get a better effect, yet we are limited to lower doses than we used to be able to give. In terms of each individual patient, I think when you're injecting them, it's very important to determine, ‘What am I going to inject today and why am I injecting that?’ You might pick a different set of muscles if somebody has other interventions being used simultaneously or if a patient is in therapy and they're working on proximal stability as opposed to finger control. You may need to sacrifice getting contractures in some muscle groups, because you are limited in how much can be dosed or in terms of what we have in our toolbox about what we can use in a particular patient.

Arthur, NLN: In the context of spasticity following brain injury, how do motor point blocks with phenol/alcohol compare to other interventions in terms of efficacy and safety?

Dr Ivanhoe: It's often in the setting of brain injury that you need to use all the interventions. I personally tend to do motor point blocks more than nerve blocks. And that will also depend on if you're trying to knock out tone in a full extremity. You're less predictable in terms of how long you might map that out. I like to do motor point blocks more because I can titrate my injection response to where that patient is in their trajectory of getting better.

Cryoneurolysis does not damage muscle, whereas phenol and alcohol do damage muscles. Not all my colleagues agree on this, but I don't like to inject the same limb multiple times with phenol because those muscles will become somewhat crunchy. Many patients will get phenol, botulinum toxins, intrathecal pumps and orthopedic surgeries in conjunction with appropriate ancillary disciplines like physical therapy, occupational therapy, and speech therapy.

Arthur, NLN: What is the impact of untreated spasticity on the long-term functional outcomes of individuals, such as consciousness, activities of daily living (ADL), and mobility skills?

Dr Ivanhoe: We often talk about how, if somebody's spasticity looks worse than it has been then we should be looking for a medical reason. But more and more, if we don't treat the spasticity, what are the medical complications we are going to foster or even create? When untreated, patients just get progressively contracted when they don't necessarily need to be. So contractures or poor positioning can lead to problems with respirations, painful spinal deformities, and pressure sores.

If you put people on a lot of oral medications and they're disorders of consciousness patients, you can keep them in that disorder where they're less engageable. People very often will underestimate the degree of cognition and awareness that’s actually going on. It can impact all activities of daily living—spasticity can affect the bladder. It can affect motoric recovery or improvement. Upper limb spasticity affects balance and gait, which can lead to more falls. There's this cascading effect, and it somewhat starts with just getting patients into a good position more acutely, which can limit some of the complications of the spasticity in all aspects of their lives. 

Cindy Ivanhoe, MD, is a clinical professor of physical medicine and rehabilitation at McGovern Medical School at The University of Texas Health Science Center at Houston, Texas. She is also director of Spasticity and Associated Syndromes of Movement (SPASM) at TIRR Memorial Hermann. Dr Ivanhoe is board-certified in physical medicine and rehabilitation and in brain injury medicine. She has served as faculty in courses across the United States and abroad and is known for her expertise in the treatment of spasticity and its role in functional recovery, medical complications of brain injury of all etiologies and severities, and as an advocate for healthcare access. Her nonprofit, IF (Ivanhoe Foundation) supports endeavors such as REEL Abilities, and others that serve to improve perceptions, opportunities, and lives of persons with brain injuries and other disabilities.